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Review Article |

Why Young Adults Hold the Key to Assessing the Obesity Epidemic in Children FREE

Joyce M. Lee, MD, MPH
[+] Author Affiliations

Author Affiliation: Division of Pediatric Endocrinology, Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor.


Arch Pediatr Adolesc Med. 2008;162(7):682-687. doi:10.1001/archpedi.162.7.682.
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Despite significant increases in prevalence rates of childhood obesity in the United States during the past 2 decades, rates of type 2 diabetes mellitus among children at the population level have not followed a similar trajectory as those in adults. In this review, hypotheses for the contrasting findings in children compared with adults are explored, as are possible links between the trends in childhood obesity rates and increases in type 2 diabetes among young adults in the United States. This review concludes with observations about the profound policy implications from current patterns of type 2 diabetes among youth and particularly young adults and a proposed research agenda regarding childhood obesity and type 2 diabetes risk over the life course.

Figures in this Article

Type 2 diabetes mellitus is a chronic disease associated with long-term microvascular complications, such as neuropathy, retinopathy, and end-stage renal disease, and macrovascular complications, including cardiovascular disease and stroke.1,2 Because of its devastating complications and reported increases in prevalence,37 type 2 diabetes has been described as one of the “major threats to human health” for the 21st century.3

Obesity is the hypothesized critical factor contributing to an increased risk for type 2 diabetes,810 and rates of obesity in the United States have increased significantly. In adults, the prevalence of obesity (body mass index [BMI] [calculated as weight in kilograms divided by height in meters squared] ≥30) has increased more than 2-fold since the 1960s,11,12 with 32.2% of adults classified as obese by 2004. Given the relation between obesity and diabetes, increases in type 2 diabetes among adults would be expected to parallel the increases in obesity and, in fact, that pattern is seen. Figure 1 shows sharp increases in obesity prevalence among US adults between 1976 and 2000, and Figure 2 shows increases in type 2 diabetes prevalence among US adults during the same period.13

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Figure 1.

Trends in obesity prevalence among US adults. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Figure 2.

Trends in type 2 diabetes mellitus prevalence among US adults. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Rates of obesity among US children (BMI ≥95th percentile for age and sex) have increased even more dramatically, with a 3-fold increase since 1976 (Figure 3).11,14,15 Presumably because of childhood obesity trends, reports surfaced in the mid-1990s regarding increasing numbers of children with type 2 diabetes. Initial studies from tertiary care clinics documented 10-fold increases in type 2 diabetes incidence between 1982 (0.7 per 100 000 population) and 1994 (7.2 per 100 000 population),16 with type 2 diabetes accounting for 8% to 45% of new-onset diabetes cases.17

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Figure 3.

Trends in obesity prevalence among US children. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Further evidence of increases in childhood type 2 diabetes was based on studies in high-risk populations. The prevalence of type 2 diabetes doubled among Pima Indian adolescents between 1977-1986 and 1987-1996,18 and type 2 diabetes incidence rates among Pima Indian children were 5.7 times higher in 1991-2003 compared with 1965-1977.19 The Chicago Childhood Diabetes Registry also reported increases in the proportion of children with type 2 diabetes among a subset of urban black and Latino children between 1985 and 2001.20

Prompted by these assessments of type 2 diabetes in high-risk groups, epidemiologic rates of childhood diabetes have been assessed more recently through larger population-based studies. Figure 4 shows population-based rates of type 2 diabetes among adolescents aged 12 to 19 years between 1988 and 2000 based on National Health and Nutrition Examination Survey (NHANES) data.21,22 Rates of type 2 diabetes among adolescents remained relatively stable, despite the notable increase in obesity prevalence among children seen during a similar period in Figure 3, in contrast to the pattern seen in adults (Figure 1 and Figure 2). Admittedly, the number of children with type 2 diabetes in these studies was low, with possible underestimation of type 2 diabetes prevalence because of treatment-based classification. However, these children were drawn from large representative population samples of 286721 and 4370 adolescents22 that oversampled for racial/ethnic minorities.

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Figure 4.

Trends in type 2 diabetes mellitus prevalence among US children aged 12 to 19 years. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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The results of additional population-based studies in children appear to be consistent with NHANES data. The Table presents a comparison of diabetes prevalence estimates from population-based studies between 1988 and 2004.2125 Although slight differences in type 2 diabetes prevalence exist because of sampling variability and classification methods (treatment based21,22 vs pathogenesis based23,24), similar rates were reported in a racially and socioeconomically diverse cohort of adolescents within an urban-suburban school district (0.12%).23 Furthermore, the SEARCH for Diabetes in Youth Study,24 a multicenter population-based study that used gold standard classification methods, reported an even lower type 2 diabetes prevalence among adolescents aged 10 to 19 years (0.04%) and children aged 0 to 19 years (0.02%).24 Except for high-risk groups (ie, Pima Indians and urban minority children), no population-based data on type 2 diabetes prevalence are available before 1988, so significant increases in type 2 diabetes rates among the population of US adolescents before 1988 cannot be ruled out.

Table Graphic Jump LocationTable. Population-Based Prevalence Rates of Diabetes Mellitus Among Children and Adolescents

It may seem difficult to reconcile the documented increases in type 2 diabetes seen in population-based studies of high-risk groups with the lack of increases in type 2 diabetes measured in broader samples, but these findings are consistent with those of the SEARCH study, which found higher incidence rates of type 2 diabetes compared with type 1 diabetes mellitus among African American, Asian American, Hispanic, and American Indian adolescents, although among US children as a whole, the incidence of type 1 diabetes was still higher than the incidence of type 2 diabetes.26 Therefore, increases in type 2 diabetes among high-risk minority groups may not yet be reflective of trends in the overall population. The lack of recent increases in type 2 diabetes rates among children compared with adults at the population level, despite significant increases in obesity, demonstrates that the overall burden of type 2 diabetes is still concentrated mostly among adults.

The absence of concurrent increases in childhood obesity and type 2 diabetes at the population level may be largely attributable to a latency period between obesity and type 2 diabetes. Figure 5 shows the hypothesized physiologic pathway leading to development of type 2 diabetes.2729 Obesity is a risk factor for development of insulin resistance, with pancreatic β cells compensating for insulin resistance by augmenting insulin secretion. The failure of the β cells to maintain adequate insulin secretion is believed to cause prediabetes, eventually leading to type 2 diabetes. Consistent with this model, studies in Pima Indians have shown that the latency period between onset of obesity and type 2 diabetes can last 10 years or longer.30 Because of this latency period, childhood obesity trends likely have a delayed effect on rates of type 2 diabetes, reflected in significant increases in type 2 diabetes among young adults who were obese as children.

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Figure 5.

Hypothesized physiologic pathway leading to development of type 2 diabetes mellitus.

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Both degree and duration of obesity likely influence the length of the latency period. A number of studies10,31 have shown that the higher the BMI, the higher the risk of incident type 2 diabetes, with a recent study32 finding an inverse linear relation between age of diagnosis of type 2 diabetes and BMI. For example, mean BMI at diagnosis was 38.3 for individuals younger than 30 years, 35.9 for individuals 46 to 50 years old, and 31.1 for individuals 66 to 70 years old, suggesting that degree of obesity will influence the timing of incident type 2 diabetes. Studies30,33 have also shown that a longer duration of obesity is associated with a higher type 2 diabetes incidence after controlling for age, sex, and current BMI. The degree and duration of obesity extending from childhood through young adulthood may confer a cumulative risk of type 2 diabetes analogous to the relation between pack-years of smoking and lung cancer33; this risk is accumulating at an unprecedented rate given recent childhood obesity trends.

In addition to absolute increases in obesity prevalence, the degree of obesity among US children has increased, resulting in shifts in the overall weight distribution.15,34 Jolliffe34 calculated the extent of obesity for US children, defined as the average amount by which each child's BMI exceeded his or her age- and sex-specific obesity threshold. Although the prevalence of obesity increased by 182% between 1971 and 2000, the extent of obesity increased by 247% during the same period.34 Children are also increasingly becoming obese at younger ages (6 months to 5 years).14 Because more US children are becoming heavier at earlier ages, younger cohorts may experience a greater degree and longer duration of obesity during their lifetime, which could lead to a shortening of the latency period and onset of type 2 diabetes in young adulthood.

Consistent with this hypothesis, recent studies6,35 suggest possible increases in rates of diabetes among US young adults. We recently assessed trends in hospitalizations associated with a diagnosis of diabetes for individuals from birth to the age of 29 years, using a nationally representative sample of hospital discharges between 1993 and 2004. During the 12-year period, we found significant increases among young adults aged 20 to 29 years (185.2 per 100 000 population in 1993 to 275.0 per 100 000 population in 2004, representing a 48% increase) but not among children 19 years or younger.35

This study could not distinguish between diabetes type. Furthermore, individuals with diabetes may not require inpatient hospitalization. However, type 2 diabetes accounts for 90% to 95% of adult diabetes,7 and according to the Centers for Disease Control and Prevention (CDC),36 hospitalizations among individuals with diabetes have decreased since 1980. Therefore, increases in population-adjusted hospitalization rates for young adults are likely an indication of increasing type 2 diabetes prevalence in the young adult population.36 Increases in particular were seen after 2000 among a generation of young adults who grew up in the midst of the childhood obesity epidemic during the late 1970s and early 1980s. The birth cohort effects of large increases in childhood obesity may be presenting just now as the first indication of significant increases in type 2 diabetes among young adults.

An epidemiologic shift to younger ages at onset of type 2 diabetes may have profound intergenerational consequences. The onset of type 2 diabetes among young women during the child-bearing years may lead to a possible “vicious cycle” of type 2 diabetes in subsequent generations because studies have shown a higher risk of obesity and type 2 diabetes among offspring with intrauterine exposure to maternal diabetes.37

Furthermore, studies suggest that early-onset type 2 diabetes may represent a more aggressive disease with regard to cardiovascular outcomes, rates of end-stage complications, and overall mortality. One recent study38 described the rates of diabetes complications for individuals with early-onset (aged 18-44 years) compared with late-onset (aged ≥45 years) type 2 diabetes after initial diagnosis. Early-onset type 2 diabetes was associated with a 14-fold higher hazard of developing a myocardial infarction compared with age- and sex-adjusted controls without diabetes, a far stronger association than found in the late-onset type 2 diabetes group, who had a 4-fold higher hazard for late-onset type 2 diabetes compared with controls.38

Because end-stage complications develop as a function of duration of disease,39 young adults with type 2 diabetes will likely face greater morbidity and mortality during their lifetime compared with individuals whose diabetes is diagnosed at older ages. One Pima Indian study40 documented higher incidence rates of end-stage renal disease and mortality among individuals with youth-onset type 2 diabetes compared with adult-onset type 2 diabetes, with a longer duration of diabetes largely accounting for these differences.

Finally, a number of studies41,42 have shown that the relative risk of death attributable to type 2 diabetes in adults is highest in the youngest age groups and declines with increasing age. Accordingly, demographers are predicting that recent childhood obesity trends will result in a shorter life expectancy for future generations as a result of diseases including type 2 diabetes.43

A life course approach to chronic disease risk suggests that risk factors and experiences early in life impact long-term health and disease outcomes,44,45 and interventions to attenuate early risk factors in childhood may lead to prevention of disease in adulthood.46 The childhood obesity epidemic has important implications for type 2 diabetes risk during the life course because of possible increases in type 2 diabetes during young adulthood. If cumulative exposure to obesity in childhood is associated with early onset of type 2 diabetes, then health care investments or policy interventions to prevent or treat childhood obesity to reduce this exposure will have important effects on the overall health of the population, although improved health and related health economic outcomes may not be noted for several years.

Given the possible link between trends in childhood obesity and trends in type 2 diabetes among young adults, health care policy and financing may need to shift focus to disease prevention interventions earlier in the life course.

First, investment in and incentives for screening and treatment of childhood obesity in the clinical setting are likely needed, as studies have shown greater reversibility of obesity at younger ages.47 Unfortunately, obesity prevention and treatment-related services for children are not usually covered by third-party payers.48 In contrast, programs for managing adult chronic diseases (type 2 diabetes, hypertension, and cardiovascular disease) have increased in number and scope.49,50 This imbalance is reflected in overall health care spending for the population, which is substantially lower in US children compared with US adults on a per capita basis, with proportional decreases in spending during the past decade for children accompanied by proportional increases in spending among adults.51

Second, schools represent a critical arena for obesity prevention among children.52 School-based interventions that promote decreased television and video viewing time,53 increased physical activity and healthy eating,54 and elimination of sugar-sweetened beverage intake55 have been shown to be effective in lowering BMI and decreasing the prevalence of obesity, suggesting the need for increased funding for conducting and monitoring the effects of school-based obesity prevention initiatives.

Third, although controversial, the importance of monitoring population trends in obesity by school-based BMI measurement56,57 is critical for assessing the effectiveness of innovative school-based policy interventions.58,59 For example, Arkansas passed legislation in 2003 that included a variety of measures to combat childhood obesity. Through school-based BMI assessment, they were able to document that multimodal interventions have apparently halted the progression of childhood obesity within 2 years of implementation.57

The CDC estimates that approximately  48.3 million individuals in the United States will have diagnosed diabetes by 2050.60 Because childhood obesity trends have not been accounted for, their projections may substantially underestimate future cases of type 2 diabetes. Therefore, further studies are needed to model the impact of the dynamics of childhood obesity on future rates and age at onset of type 2 diabetes and to assess both the effectiveness and cost-effectiveness of interventions for preventing type 2 diabetes over the life course.

Modeling the link between childhood obesity and type 2 diabetes risk over the life course will be critical for estimating the changing rates of microvascular and macrovascular complications and changes in life expectancy owing to trends in childhood obesity. Information from the model will be highly relevant for understanding the impact of potential increases in incident type 2 diabetes in the clinical setting, in terms of access to and provision of services for those affected, and the potential future financial burden on Medicare, the primary payer for end-stage renal disease. It will also be essential for assessing the effectiveness of interventions across the life course for preventing type 2 diabetes and its complications. Using a life-time simulation, Herman et al61 showed that both lifestyle modification and metformin were cost-effective interventions for delaying or preventing the onset of type 2 diabetes among high-risk adults, concluding that diabetes prevention interventions among high-risk adults represent a worthwhile investment for policy makers. Information regarding the cost-effectiveness of obesity prevention and treatment interventions earlier in the life course is needed for comparison, which will guide future health policy to evaluate which high-risk demographic groups should be targeted for interventions and to determine at what ages across the life course interventions should be introduced to achieve maximal benefit.

One recent study19 in the Pima Indians showed that between 1965 and 2003 the greatest increases in type 2 diabetes incidence occurred among children aged 5 to 14 years and, in fact, decreases in type 2 diabetes incidence occurred among individuals aged 25 to 34 years. This epidemiologic shift to an even earlier onset of type 2 diabetes, reaching into childhood and adolescence, may be a scenario faced by the entire US population if the childhood obesity epidemic continues unabated. Given that the current US health care system is not designed to promote disease prevention over the life course, the traditional models of “pediatric” and “adult” health care will need to be challenged, leading to development of new models of care that address long-term chronic disease risk originating in childhood and extending into adulthood. There are several diseases to which such a new life-course model could be applied, but perhaps no condition more prevalent among children than obesity and no consequence more clinically severe than type 2 diabetes for which a life-course model will be a crucial platform for success.

Correspondence: Joyce M. Lee, MD, MPH, Division of Pediatric Endocrinology, Child Health Evaluation and Research Unit, University of Michigan, 300 NIB, Room 6E08, Campus Box 5456, Ann Arbor, MI 48109-5456 (joyclee@umich.edu).

Accepted for Publication: January 4, 2008.

Financial Disclosure: None reported.

Funding/Support: Dr Lee was supported by the Clinical Sciences Scholars Program at the University of Michigan. This study used the Modeling Core of the Michigan Diabetes Research and Training Center, funded by National Institutes of Health grant 5P60 DK20572 from the National Institute of Diabetes and Digestive and Kidney Diseases.

Additional Contributions: Matthew Davis, MD, MAPP, Gary Freed, MD, MPH, James Gurney, PhD, Beth Tarini, MD, MS, and Sandeep Vijan, MD, provided helpful comments during the preparation of the manuscript.

Klein  R Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care 1995;18 (2) 258- 268
PubMed
Orchard  TJDorman  JSMaser  RE  et al.  Prevalence of complications in IDDM by sex and duration: Pittsburgh Epidemiology of Diabetes Complications Study II. Diabetes 1990;39 (9) 1116- 1124
PubMed
Zimmet  PAlberti  KGShaw  J Global and societal implications of the diabetes epidemic. Nature 2001;414 (6865) 782- 787
PubMed
Mokdad  AHBowman  BAFord  ESVinicor  FMarks  JSKoplan  JP The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286 (10) 1195- 1200
PubMed
Mokdad  AHFord  ESBowman  BA  et al.  The continuing increase of diabetes in the US [letter]. Diabetes Care 2001;24 (2) 412
PubMed
Mokdad  AHFord  ESBowman  BA  et al.  Diabetes trends in the U.S.: 1990-1998. Diabetes Care 2000;23 (9) 1278- 1283
PubMed
Engelgau  MMGeiss  LSSaaddine  JB  et al.  The evolving diabetes burden in the United States. Ann Intern Med 2004;140 (11) 945- 950
PubMed
Goran  MIBall  GDCruz  ML Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Endocrinol Metab 2003;88 (4) 1417- 1427
PubMed
Hannon  TSRao  GArslanian  SA Childhood obesity and type 2 diabetes mellitus. Pediatrics 2005;116 (2) 473- 480
PubMed
Knowler  WCPettitt  DJSaad  MF  et al.  Obesity in the Pima Indians: its magnitude and relationship with diabetes. Am J Clin Nutr 1991;53 (6) ((suppl)) 1543S- 1551S
PubMed
Ogden  CLCarroll  MDCurtin  LR McDowell  MATabak  CJFlegal  KM Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295 (13) 1549- 1555
PubMed
Flegal  KMCarroll  MDOgden  CLJohnson  CL Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002;288 (14) 1723- 1727
PubMed
Gregg  EWCadwell  BLCheng  YJ  et al.  Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the US. Diabetes Care 2004;27 (12) 2806- 2812
PubMed
Ogden  CLFlegal  KMCarroll  MDJohnson  CL Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002;288 (14) 1728- 1732
PubMed
Troiano  RPFlegal  KM Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 1998;101 (3, pt 2) 497- 504
PubMed
Pinhas-Hamiel  ODolan  LMDaniels  SRStandiford  DKhoury  PRZeitler  P Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr 1996;128 (5, pt 1) 608- 615
PubMed
Fagot-Campagna  APettitt  DJEngelgau  MM  et al.  Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr 2000;136 (5) 664- 672
PubMed
Dabelea  DHanson  RLBennett  PHRoumain  JKnowler  WCPettitt  DJ Increasing prevalence of type II diabetes in American Indian children. Diabetologia 1998;41 (8) 904- 910
PubMed
Pavkov  MEHanson  RLKnowler  WCBennett  PHKrakoff  JNelson  RG Changing patterns of type 2 diabetes incidence among Pima Indians. Diabetes Care 2007;30 (7) 1758- 1763
PubMed
Lipton  RBDrum  MBurnet  D  et al.  Obesity at the onset of diabetes in an ethnically diverse population of children: what does it mean for epidemiologists and clinicians? Pediatrics 2005;115 (5) e553- e560
PubMed10.1542/peds.2004-1448
Fagot-Campagna  ASaaddine  JBFlegal  KMBeckles  GL Diabetes, impaired fasting glucose, and elevated HbA1c in U.S. adolescents: the Third National Health and Nutrition Examination Survey. Diabetes Care 2001;24 (5) 834- 837
PubMed
Duncan  GE Prevalence of diabetes and impaired fasting glucose levels among US adolescents: National Health and Nutrition Examination Survey, 1999-2002. Arch Pediatr Adolesc Med 2006;160 (5) 523- 528
PubMed
Dolan  LMBean  JD'Alessio  D  et al.  Frequency of abnormal carbohydrate metabolism and diabetes in a population-based screening of adolescents. J Pediatr 2005;146 (6) 751- 758
PubMed
Liese  ADD’Agostino  RB  JrHamman  RF  et al.  The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006;118 (4) 1510- 1518
PubMed
Lee  JMHerman  WH McPheeters  MLGurney  JG An epidemiologic profile of children with diabetes in the U.S. Diabetes Care 2006;29 (2) 420- 421
PubMed
Dabelea  DBell  RAD'Agostino  RB  Jr  et al.  Incidence of diabetes in youth in the United States. JAMA 2007;297 (24) 2716- 2724
PubMed
Gungor  NHannon  TLibman  IBacha  FArslanian  S Type 2 diabetes mellitus in youth: the complete picture to date. Pediatr Clin North Am 2005;52 (6) 1579- 1609
PubMed
Cruz  MLShaibi  GQWeigensberg  MJSpruijt-Metz  DBall  GDGoran  MI Pediatric obesity and insulin resistance: chronic disease risk and implications for treatment and prevention beyond body weight modification. Annu Rev Nutr 2005;25435- 468
PubMed
Inzucchi  SESherwin  RS The prevention of type 2 diabetes mellitus. Endocrinol Metab Clin North Am 2005;34 (1) 199- 219, viii
PubMed
Everhart  JE Duration of obesity increases the incidence of NIDDM. Diabetes 1992;41 (2) 235- 240
PubMed
Fox  CSPencina  MJMeigs  JBVasan  RSLevitzky  YSD'Agostino  RB  Sr Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation 2006;113 (25) 2914- 2918
PubMed
Hillier  TAPedula  KL Characteristics of an adult population with newly diagnosed type 2 diabetes: the relation of obesity and age of onset. Diabetes Care 2001;24 (9) 1522- 1527
PubMed
Brancati  FLWang  NYMead  LALiang  KYKlag  MJ Body weight patterns from 20 to 49 years of age and subsequent risk for diabetes mellitus: the Johns Hopkins Precursors Study. Arch Intern Med 1999;159 (9) 957- 963
PubMed
Jolliffe  D Extent of overweight among US children and adolescents from 1971 to 2000. Int J Obes Relat Metab Disord 2004;28 (1) 4- 9
PubMed
Lee  JMOkumura  MJFreed  GLMenon  RKDavis  MM Trends in hospitalizations for diabetes among children and young adults: United States, 1993-2004. Diabetes Care 2007;30 (12) 3035- 3039
PubMed
Centers for Disease Control and Prevention, Diabetes Data and Trends. http://www.cdc.gov/diabetes/statistics/dmany/fig7.htm. Accessed August 2, 2007
Dabelea  DHanson  RLLindsay  RS  et al.  Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships. Diabetes 2000;49 (12) 2208- 2211
PubMed
Hillier  TAPedula  KL Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth. Diabetes Care 2003;26 (11) 2999- 3005
PubMed
Nathan  DM Long-term complications of diabetes mellitus. N Engl J Med 1993;328 (23) 1676- 1685
PubMed
Pavkov  MEBennett  PHKnowler  WCKrakoff  JSievers  MLNelson  RG Effect of youth-onset type 2 diabetes mellitus on incidence of end-stage renal disease and mortality in young and middle-aged Pima Indians. JAMA 2006;296 (4) 421- 426
PubMed
Tierney  EFGeiss  LSEngelgau  MM  et al.  Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota. Am J Public Health 2001;91 (1) 84- 92
PubMed
Saydah  SHEberhardt  MSLoria  CMBrancati  FL Age and the burden of death attributable to diabetes in the United States. Am J Epidemiol 2002;156 (8) 714- 719
PubMed
Olshansky  SJPassaro  DJHershow  RC  et al.  A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352 (11) 1138- 1145
PubMed
Kuh  DBen-Shlomo  Y A Life Course Approach to Chronic Disease Epidemiology.  Oxford, England Oxford University Press2004;
Forrest  CBRiley  AW Childhood origins of adult health: a basis for life-course health policy. Health Aff (Millwood) 2004;23 (5) 155- 164
PubMed
Halfon  NHochstein  M Life course health development: an integrated framework for developing health, policy, and research. Milbank Q 2002;80 (3) 433- 479
PubMed
Guo  SSWu  WChumlea  WCRoche  AF Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. Am J Clin Nutr 2002;76 (3) 653- 658
PubMed
Schwimmer  JB Childhood obesity: the case for coverage. Harv Health Policy Rev 2003;4 (2) 62- 72
Wagner  EHAustin  BTKorff  MV Organizing care for patients with chronic illness. Milbank Q 1996;74 (4) 511- 544
PubMed
Wagner  EHDavis  CSchaefer  JVon Korff  MAustin  B A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q 1999;7 (3) 56- 66
PubMed
Freed  GLFant  K The impact of the “aging of America” on children. Health Aff (Millwood) 2004;23 (2) 168- 174
PubMed
Story  MKaphingst  KMFrench  S The role of schools in obesity prevention. Future Child 2006;16 (1) 109- 142
PubMed
Robinson  TN Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282 (16) 1561- 1567
PubMed
Gortmaker  SLPeterson  KWiecha  J  et al.  Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med 1999;153 (4) 409- 418
PubMed
James  JThomas  PCavan  DKerr  D Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328 (7450) 1237
PubMed
Kantor  J As obesity fight hits cafeteria, many fear a note from school. New York Times. January8 2007;http://www.nytimes.com/2007/01/08/health/08obesity.html?_r=1&oref=slogin. Accessed February 15, 2007
Ryan  KWCard-Higginson  P McCarthy  SGJustus  MBThompson  JW Arkansas fights fat: translating research into policy to combat childhood and adolescent obesity. Health Aff (Millwood) 2006;25 (4) 992- 1004
PubMed
Sallis  JF McKenzie  TLConway  TL  et al.  Environmental interventions for eating and physical activity: a randomized controlled trial in middle schools. Am J Prev Med 2003;24 (3) 209- 217
PubMed
French  SAStables  G Environmental interventions to promote vegetable and fruit consumption among youth in school settings. Prev Med 2003;37 (6, pt 1) 593- 610
PubMed
Narayan  KMVBoyle  JPGeiss  LSSaaddine  JBThompson  TJ Impact of recent increase in incidence on future diabetes burden. Diabetes Care 2006;29 (9) 2114- 2116
PubMed
Herman  WHHoerger  TJBrandle  M  et al.  The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med 2005;142 (5) 323- 332
PubMed

Figures

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Figure 1.

Trends in obesity prevalence among US adults. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Figure 2.

Trends in type 2 diabetes mellitus prevalence among US adults. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Figure 3.

Trends in obesity prevalence among US children. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Figure 4.

Trends in type 2 diabetes mellitus prevalence among US children aged 12 to 19 years. NHES indicates National Health Examination Survey; NHANES, National Health and Nutrition Examination Survey.

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Figure 5.

Hypothesized physiologic pathway leading to development of type 2 diabetes mellitus.

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Tables

Table Graphic Jump LocationTable. Population-Based Prevalence Rates of Diabetes Mellitus Among Children and Adolescents

References

Klein  R Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care 1995;18 (2) 258- 268
PubMed
Orchard  TJDorman  JSMaser  RE  et al.  Prevalence of complications in IDDM by sex and duration: Pittsburgh Epidemiology of Diabetes Complications Study II. Diabetes 1990;39 (9) 1116- 1124
PubMed
Zimmet  PAlberti  KGShaw  J Global and societal implications of the diabetes epidemic. Nature 2001;414 (6865) 782- 787
PubMed
Mokdad  AHBowman  BAFord  ESVinicor  FMarks  JSKoplan  JP The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286 (10) 1195- 1200
PubMed
Mokdad  AHFord  ESBowman  BA  et al.  The continuing increase of diabetes in the US [letter]. Diabetes Care 2001;24 (2) 412
PubMed
Mokdad  AHFord  ESBowman  BA  et al.  Diabetes trends in the U.S.: 1990-1998. Diabetes Care 2000;23 (9) 1278- 1283
PubMed
Engelgau  MMGeiss  LSSaaddine  JB  et al.  The evolving diabetes burden in the United States. Ann Intern Med 2004;140 (11) 945- 950
PubMed
Goran  MIBall  GDCruz  ML Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Endocrinol Metab 2003;88 (4) 1417- 1427
PubMed
Hannon  TSRao  GArslanian  SA Childhood obesity and type 2 diabetes mellitus. Pediatrics 2005;116 (2) 473- 480
PubMed
Knowler  WCPettitt  DJSaad  MF  et al.  Obesity in the Pima Indians: its magnitude and relationship with diabetes. Am J Clin Nutr 1991;53 (6) ((suppl)) 1543S- 1551S
PubMed
Ogden  CLCarroll  MDCurtin  LR McDowell  MATabak  CJFlegal  KM Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295 (13) 1549- 1555
PubMed
Flegal  KMCarroll  MDOgden  CLJohnson  CL Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002;288 (14) 1723- 1727
PubMed
Gregg  EWCadwell  BLCheng  YJ  et al.  Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the US. Diabetes Care 2004;27 (12) 2806- 2812
PubMed
Ogden  CLFlegal  KMCarroll  MDJohnson  CL Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002;288 (14) 1728- 1732
PubMed
Troiano  RPFlegal  KM Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 1998;101 (3, pt 2) 497- 504
PubMed
Pinhas-Hamiel  ODolan  LMDaniels  SRStandiford  DKhoury  PRZeitler  P Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr 1996;128 (5, pt 1) 608- 615
PubMed
Fagot-Campagna  APettitt  DJEngelgau  MM  et al.  Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr 2000;136 (5) 664- 672
PubMed
Dabelea  DHanson  RLBennett  PHRoumain  JKnowler  WCPettitt  DJ Increasing prevalence of type II diabetes in American Indian children. Diabetologia 1998;41 (8) 904- 910
PubMed
Pavkov  MEHanson  RLKnowler  WCBennett  PHKrakoff  JNelson  RG Changing patterns of type 2 diabetes incidence among Pima Indians. Diabetes Care 2007;30 (7) 1758- 1763
PubMed
Lipton  RBDrum  MBurnet  D  et al.  Obesity at the onset of diabetes in an ethnically diverse population of children: what does it mean for epidemiologists and clinicians? Pediatrics 2005;115 (5) e553- e560
PubMed10.1542/peds.2004-1448
Fagot-Campagna  ASaaddine  JBFlegal  KMBeckles  GL Diabetes, impaired fasting glucose, and elevated HbA1c in U.S. adolescents: the Third National Health and Nutrition Examination Survey. Diabetes Care 2001;24 (5) 834- 837
PubMed
Duncan  GE Prevalence of diabetes and impaired fasting glucose levels among US adolescents: National Health and Nutrition Examination Survey, 1999-2002. Arch Pediatr Adolesc Med 2006;160 (5) 523- 528
PubMed
Dolan  LMBean  JD'Alessio  D  et al.  Frequency of abnormal carbohydrate metabolism and diabetes in a population-based screening of adolescents. J Pediatr 2005;146 (6) 751- 758
PubMed
Liese  ADD’Agostino  RB  JrHamman  RF  et al.  The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006;118 (4) 1510- 1518
PubMed
Lee  JMHerman  WH McPheeters  MLGurney  JG An epidemiologic profile of children with diabetes in the U.S. Diabetes Care 2006;29 (2) 420- 421
PubMed
Dabelea  DBell  RAD'Agostino  RB  Jr  et al.  Incidence of diabetes in youth in the United States. JAMA 2007;297 (24) 2716- 2724
PubMed
Gungor  NHannon  TLibman  IBacha  FArslanian  S Type 2 diabetes mellitus in youth: the complete picture to date. Pediatr Clin North Am 2005;52 (6) 1579- 1609
PubMed
Cruz  MLShaibi  GQWeigensberg  MJSpruijt-Metz  DBall  GDGoran  MI Pediatric obesity and insulin resistance: chronic disease risk and implications for treatment and prevention beyond body weight modification. Annu Rev Nutr 2005;25435- 468
PubMed
Inzucchi  SESherwin  RS The prevention of type 2 diabetes mellitus. Endocrinol Metab Clin North Am 2005;34 (1) 199- 219, viii
PubMed
Everhart  JE Duration of obesity increases the incidence of NIDDM. Diabetes 1992;41 (2) 235- 240
PubMed
Fox  CSPencina  MJMeigs  JBVasan  RSLevitzky  YSD'Agostino  RB  Sr Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation 2006;113 (25) 2914- 2918
PubMed
Hillier  TAPedula  KL Characteristics of an adult population with newly diagnosed type 2 diabetes: the relation of obesity and age of onset. Diabetes Care 2001;24 (9) 1522- 1527
PubMed
Brancati  FLWang  NYMead  LALiang  KYKlag  MJ Body weight patterns from 20 to 49 years of age and subsequent risk for diabetes mellitus: the Johns Hopkins Precursors Study. Arch Intern Med 1999;159 (9) 957- 963
PubMed
Jolliffe  D Extent of overweight among US children and adolescents from 1971 to 2000. Int J Obes Relat Metab Disord 2004;28 (1) 4- 9
PubMed
Lee  JMOkumura  MJFreed  GLMenon  RKDavis  MM Trends in hospitalizations for diabetes among children and young adults: United States, 1993-2004. Diabetes Care 2007;30 (12) 3035- 3039
PubMed
Centers for Disease Control and Prevention, Diabetes Data and Trends. http://www.cdc.gov/diabetes/statistics/dmany/fig7.htm. Accessed August 2, 2007
Dabelea  DHanson  RLLindsay  RS  et al.  Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships. Diabetes 2000;49 (12) 2208- 2211
PubMed
Hillier  TAPedula  KL Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth. Diabetes Care 2003;26 (11) 2999- 3005
PubMed
Nathan  DM Long-term complications of diabetes mellitus. N Engl J Med 1993;328 (23) 1676- 1685
PubMed
Pavkov  MEBennett  PHKnowler  WCKrakoff  JSievers  MLNelson  RG Effect of youth-onset type 2 diabetes mellitus on incidence of end-stage renal disease and mortality in young and middle-aged Pima Indians. JAMA 2006;296 (4) 421- 426
PubMed
Tierney  EFGeiss  LSEngelgau  MM  et al.  Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota. Am J Public Health 2001;91 (1) 84- 92
PubMed
Saydah  SHEberhardt  MSLoria  CMBrancati  FL Age and the burden of death attributable to diabetes in the United States. Am J Epidemiol 2002;156 (8) 714- 719
PubMed
Olshansky  SJPassaro  DJHershow  RC  et al.  A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352 (11) 1138- 1145
PubMed
Kuh  DBen-Shlomo  Y A Life Course Approach to Chronic Disease Epidemiology.  Oxford, England Oxford University Press2004;
Forrest  CBRiley  AW Childhood origins of adult health: a basis for life-course health policy. Health Aff (Millwood) 2004;23 (5) 155- 164
PubMed
Halfon  NHochstein  M Life course health development: an integrated framework for developing health, policy, and research. Milbank Q 2002;80 (3) 433- 479
PubMed
Guo  SSWu  WChumlea  WCRoche  AF Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. Am J Clin Nutr 2002;76 (3) 653- 658
PubMed
Schwimmer  JB Childhood obesity: the case for coverage. Harv Health Policy Rev 2003;4 (2) 62- 72
Wagner  EHAustin  BTKorff  MV Organizing care for patients with chronic illness. Milbank Q 1996;74 (4) 511- 544
PubMed
Wagner  EHDavis  CSchaefer  JVon Korff  MAustin  B A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q 1999;7 (3) 56- 66
PubMed
Freed  GLFant  K The impact of the “aging of America” on children. Health Aff (Millwood) 2004;23 (2) 168- 174
PubMed
Story  MKaphingst  KMFrench  S The role of schools in obesity prevention. Future Child 2006;16 (1) 109- 142
PubMed
Robinson  TN Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282 (16) 1561- 1567
PubMed
Gortmaker  SLPeterson  KWiecha  J  et al.  Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med 1999;153 (4) 409- 418
PubMed
James  JThomas  PCavan  DKerr  D Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328 (7450) 1237
PubMed
Kantor  J As obesity fight hits cafeteria, many fear a note from school. New York Times. January8 2007;http://www.nytimes.com/2007/01/08/health/08obesity.html?_r=1&oref=slogin. Accessed February 15, 2007
Ryan  KWCard-Higginson  P McCarthy  SGJustus  MBThompson  JW Arkansas fights fat: translating research into policy to combat childhood and adolescent obesity. Health Aff (Millwood) 2006;25 (4) 992- 1004
PubMed
Sallis  JF McKenzie  TLConway  TL  et al.  Environmental interventions for eating and physical activity: a randomized controlled trial in middle schools. Am J Prev Med 2003;24 (3) 209- 217
PubMed
French  SAStables  G Environmental interventions to promote vegetable and fruit consumption among youth in school settings. Prev Med 2003;37 (6, pt 1) 593- 610
PubMed
Narayan  KMVBoyle  JPGeiss  LSSaaddine  JBThompson  TJ Impact of recent increase in incidence on future diabetes burden. Diabetes Care 2006;29 (9) 2114- 2116
PubMed
Herman  WHHoerger  TJBrandle  M  et al.  The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med 2005;142 (5) 323- 332
PubMed

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